The Potential for Using Excise Taxes to Reduce Smoking

We examine the potential for reducing cigarette smoking through increases in cigarette excise taxes by estimating the price elasticity of demand for cigarettes. Using information on individual smoking behavior for a sample of adults in the 1976 Health Interview Survey, we estimate the adult price elasticity of demand for cigarettes to be -.45. Moreover, we find that price has its greatest effect on the smoking behavior of young males and that it operates primarily on the decision to begin smoking regularly rather than via adjustments in the quantity of cigarettes smoked by smokers. It follows that, if future reductions in cigarette smoking are desired, Federal excise tax policy can be a potent tool to accomplish this goal, but only in the long run. An excise tax increase, if maintained in real terms, would discourage smoking participation by successive cohorts of young adults and those reduced smoking levels would be reflected in aggregate smoking as these cohorts mature. In the short run however, the impact of an excise tax increase on aggregate cigarette consumption would be relatively small.

Experience with Pregnancy, the Demand for Prenatal Care and the Production of Surviving Infants

The object of this research is to develop a model of household demand for prenatal care and attempt to measure the productive value of prenatal care per se on infant health as measured by survival. Traditionally, infant mortality rates have been used as indices of a nation\u27s health status. Since the U.S. has lagged significantly behind other developed nations in reducing infant mortality since the mid-1950\u27s, there have been charges of a malfunction in the U.S. health delivery system. Particularly in the area of infant health, critics have charged that more prenatal care Inputs are needed and that they should be directed specifically towards so-called high risk mothers. Others have questioned the value of input intensive prenatal care, claiming its marginal product is low, cost high and efficacy unproven. An economic model is developed in which the demand for healthy children is viewed as being derived from the demand for children per se. In a world where families cannot substantially effect the outcome of Individual pregnancies by varying inputs, it is demonstrated that measured infant mortality rates will be not only a function of health status but also fertility decisions, in a world where families can vary inputs, it is argued that prenatal care, as the most pregnancy relevant related input, should be a good index of the total demand for pregnancy related inputs. It is argued that the level of inputs will be positively correlated with income, tend to increase in families who have experienced pregnancy losses and decrease as family size increases, particularly if marginal children are less wanted as family size increases. Demand and production relationships are estimated using data from the 1970 New York City birth cohort. The data set consists primarily of birth and linked death certificates for the period January to June, 1970 and contains 54,000 observations after editing. Several different dependent variables are utilized to estimate the demand for care. They Include a dichotomous care/no care variable, the interval to the first visit and the number of visits. Significant empirical findings include: (1 ) the decision whether or not to seek care Is most strongly influenced by legitimacy status; (2) the demand for care is effected by past experience as predicted by the model in that families with more live children demand less care and those with a history of losses demand more care; (3) substantially less care is demanded by blacks, foreign born and Puerto Rican born mothers even when other variables are accounted for; (4) less care, other things equal, is obtained in specially designated Maternal and Infant Care Project areas, despite the presence of these special projects to encourage the use of care by high risk mothers of low socio-economic status; (5) the amount of care a mother receives is substantially determined by obstetrical protocol and does not seem to reflect her previous pregnancy experience. Outcome measures Include birth weight, infant death, neonatal and postneonatal death. Regarding birth weight significant findings include; (1 ) birth weight differentials atrributable to race, ethnicity, nativity or legitimacy characteristics are substantially reduced by taking account of differentials in the level of care received; (2 ) the net gain in birth weight attributable to a full complement of prenatal care (303 grams) as compared with no care is substantial when comapred with the birth weights of high risk infants; (3) previous experience of pregnancy successes and losses are reflected by increments or decrements in birth weight. In comparing results of outcome regressions for neonatal and postneonatal mortality, it is found that other things equal, prenatal care has a positive effect on survival during the neonatal period but no effect during the postneonatal period. Hence, it is argued that care per se has real value in improving pregnancy outcomes and is not primarily acting as a proxy variable for wantedness or other unmeasured inputs. The results of using FIML logit estimators on the dichotomous dependent variables biased on a subsample of observations do not agree with the OLS estimates based on the entire sample. It is suggested that econometricians need to more fully explore the relationship between the value of these two techniques, particularly in very large data sets

Time-Utilization of a Population of General Practitioners in a Prepaid Group Practice

A population of seven general surgeons in a prepaid group practice previously shown to have a mean operative work load of 9.2 HE per week were found to have a mean standardized seven day working week of 56.2 hours exclusive of evening activities. The surgeons also devoted a mean of 6.7 evening hours to professional activities for a total working week of 62.9 hours. Comparisons of the time utilization of this population of general surgeons with a population of previously studied community surgeons revealed that the prepaid group surgeons were able to maintain a surgical output more than double that of the community surgeons without having to devote twice as much time to professional activities. Economies in the utilization of surgical manpower in the prepaid group appear to stem from geographic and specialty restrictions on the scope of work of the surgeons, from a reduction of waiting time in the office, and from the utilization of paraprofessional personnel for operative assisting.

Expenditures on Health Care for Children and Pregnant Women

The chronic health care crisis in the United States is primarily the result of rapidly rising health care costs which leave millions of children and pregnant women without health insurance, with restricted access to health care, and at risk for poor health. A better understanding of the current system is key to any reform effort. The authors analyze estimates of annual expenditures on medical care services for children covering the period from conception through age 18 years, including expenditures on pregnancy and delivery. They focus their attention on the distribution of health care expenditures by type of service and source of payment, on how expenditures differ for children of different ages and for adults, and on the rate of growth in expenditures on health care for children. The authors suggest that, because there has been a decline in the relative share of expenditures accounted for by children, efforts to expand third-party financing of their health care will be less likely to overwhelm the system than would efforts to expand coverage to other groups. Families who are especially in need of extended health care coverage are those of children with major illnesses who are exposed to catastrophic costs. Efforts at cost containment may be most effective if focused on pregnancy and newborn care, areas in which expenditures have grown extremely rapidly in recent years. Finally, the authors conclude that, if expansion of health insurance coverage for children in the near term were to be incremental, expanded coverage for children 3 to 12 years old would probably have the smallest budgetary impact of any expansion in access to care.

Tele-education model for primary care providers to advance diabetes equity: Findings from Project ECHO Diabetes

IntroductionIn the US, many individuals with diabetes do not have consistent access to endocrinologists and therefore rely on primary care providers (PCPs) for their diabetes management. Project ECHO (Extension for Community Healthcare Outcomes) Diabetes, a tele-education model, was developed to empower PCPs to independently manage diabetes, including education on diabetes technology initiation and use, to bridge disparities in diabetes.MethodsPCPs (n=116) who participated in Project ECHO Diabetes and completed pre- and post-intervention surveys were included in this analysis. The survey was administered in California and Florida to participating PCPs via REDCap and paper surveys. This survey aimed to evaluate practice demographics, protocols with adult and pediatric T1D management, challenges, resources, and provider knowledge and confidence in diabetes management. Differences and statistical significance in pre- and post-intervention responses were evaluated via McNemar’s tests.ResultsPCPs reported improvement in all domains of diabetes education and management. From baseline, PCPs reported improvement in their confidence to serve as the T1D provider for their community (pre vs post: 43.8% vs 68.8%, p=0.005), manage insulin therapy (pre vs post: 62.8% vs 84.3%, p=0.002), and identify symptoms of diabetes distress (pre vs post: 62.8% vs 84.3%, p=0.002) post-intervention. Compared to pre-intervention, providers reported significant improvement in their confidence in all aspects of diabetes technology including prescribing technology (41.2% vs 68.6%, p=0.001), managing insulin pumps (41.2% vs 68.6%, p=0.001) and hybrid closed loop (10.2% vs 26.5%, p=0.033), and interpreting sensor data (41.2% vs 68.6%, p=0.001) post-intervention.DiscussionPCPs who participated in Project ECHO Diabetes reported increased confidence in diabetes management, with notable improvement in their ability to prescribe, manage, and troubleshoot diabetes technology. These data support the use of tele-education of PCPs to increase confidence in diabetes technology management as a feasible strategy to advance equity in diabetes management and outcomes